CME INDIA Presentation by Dr. A. K. Arya, Consultant Physician and Diabetologist, Ex HOD Medical Unit, CSIR NML (Govt. of India), Jamshedpur.

What Physicians Need to Advice Patients About Diabetic Foot Care?

Foot facts worldwide

Over 1,000,000 amputations per year.
Every 30 seconds a leg is lost to diabetes.
Loss of limb is the outcome of treatment of diabetic foot in major part of the country.
People with diabetes are 25 times more likely to lose a leg than people without the condition.
Throughout the world, up to 70% of all leg amputations happen to people with diabetes.
In developed countries one in every six people with diabetes will have an ulcer during their lifetime.
In developing countries, foot problems related to diabetes are thought to be even more common.
85% of diabetes-related lower extremity amputations are preceded by a foot ulcer.

Why people with diabetes require good care of their feet?

  • There are several reasons:
    • Loss of sensation with increased risk of injury.
    • Poor circulation causing delayed healing.
    • Higher likelihood of developing infections that go unnoticed and spread widely leading to gangrene.
    • Diabetes foot ulcers are the most common cause for prolonged hospitalizations.
  • Diabetes is the most important cause of non-traumatic foot amputations.
What Physicians Need to Advice Patients About Diabetic Foot Care?

Prevention is Possible

  • Up to 85% of all diabetes-related amputations can be prevented.
  • Education and podiatry are the most cost-effective strategies.

Cornerstones of Prevention

  1. Regular inspection and examination of feet and footwear.
  2. Identification of the high-risk foot.
  3. Individuals with diabetes should undergo regular foot examinations conducted by a healthcare provider.

Lifetime risk for foot ulcer in diabetic patients is 15%

  • 20% of these leg wound would lead to amputation.                 
  • 50% of unilateral amputation would also lose their other limbs in 3-5 years.
  • 5% mortality after amputation is 30-70%.
  • Diabetic foot ulcers occur in age of 35-45 yrs. (In India).
  • Each hospitalization for foot ulcer in India costs Rs. 25 to 30 thousand.
What Physicians Need to Advice Patients About Diabetic Foot Care?

Prevent these scary scenarios

  • Learn to take good care of your feet.
  • Practice what you learn every day.
  • Foot problems must be detected and treated properly.
  • Take help of a Foot Care specialist or your Diabetes Care Team.

You can prevent major foot problems, if you

Learn to recognize signs of early foot problems.
Inspect your feet daily.
Keep your feet clean and dry.
Trim your toenails carefully.
Protect your feet with appropriate footwear.
Have your doctor or nurse examine your feet regularly (especially if you have any loss of sensation in your feet).
What Physicians Need to Advice Patients About Diabetic Foot Care?

Care for feet

What Physicians Need to Advice Patients About Diabetic Foot Care?

Make a routine to inspect

What Physicians Need to Advice Patients About Diabetic Foot Care?

Never ignore

What Physicians Need to Advice Patients About Diabetic Foot Care?

Smooth corns and calluses removal: Do it gently

  • Check with the doctor/podiatrist before using a pumice stone.
  • Use pumice stone after bathing or showering.
  • Don’t cut corns and calluses yourself.
  • Don’t use razor blades, corn plasters, or liquid corn and callus removers – they can damage the skin.

Take care of your toenails

  • Toenails should be trimmed regularly:
    • With clippers after bath/shower.
    • Cut toenails straight across and smooth with a nail file.
    • Don’t cut into the corners of the toenail.
  • If toenails are thick or yellowed, or nails curve and grow into the skin then you may want a podiatrist (foot doctor) to cut your toenails
What Physicians Need to Advice Patients About Diabetic Foot Care?

Preventing foot problems

What Physicians Need to Advice Patients About Diabetic Foot Care?

Know your shoes and never go barefoot

What Physicians Need to Advice Patients About Diabetic Foot Care?

Protect your feet from hot and cold.

  • Keep your feet away from radiators and open fires.
  • Do not use hot water bottles/bag on feet.
  • Lined boots are good in winter to keep your feet warm and socks at night

Keep the blood flowing to the feet.

  • Keep feet up when sitting.
  • Exercises for the feet
    • Wiggle toes for 5 minutes, 2 or 3 times a day
    • Move ankles up and down and in and out.
  • Don’t
    • Cross legs
    • Wear tight socks, elastic or rubber bands, or garters around your legs.
  • Don’t smoke
    •  Smoking reduces blood flow to feet.
  • Control
    • Blood glucose, blood pressure and cholesterol.

Exercise

  • 30 minutes moderate intensity on most days preferably all
  • Helps to:
    • Increased insulin sensitivity.
    • Decreased insulin requirements.
    • Weight reduction.
    • Lipid control.
    • Blood pressure control.
  • Be careful:
    • When exercising.
    • Walk and exercise in comfortable shoes.
    • Do not exercise when you have open sores on your feet.

Identification of a problem

  • Daily inspection of the feet note:
    • Broken skin
    • Redness
    • Swelling
    • Corns/callus
    • Black/blue areas
  • Report to nurse/GP or podiatrist for assessment if you detect any of these problems

Hope

What Physicians Need to Advice Patients About Diabetic Foot Care?

Measures for evaluation & treatment of diabetic foot

What Physicians Need to Advice Patients About Diabetic Foot Care?

Footwear

What Physicians Need to Advice Patients About Diabetic Foot Care?

Which behavior and lifestyle-changing strategies do we teach people with diabetes when they are at high risk?

When buying shoes:

  • Buy in the afternoon.
  • Measure both feet.
  • Stand up to fit.
  • Wear in slowly.
  • Never wear new shoes all day.
  • Before putting on shoes, check for rough spots or loose objects.
  • Use sunblock on exposed skin.
  • At least 3 meter from heater.
  • Turn off electric blankets.
  • No hot water bottles.
  • Never walk barefoot.

Quick Take-Away

  • Periodic examination of foot is mandatory in all people with diabetes.
  • Identification of early foot problems can prevent major events & cost.
  • Identification of high-risk foot is possible at primary care setting.
  • Education of physician and patient is important for prevention of foot complications.

CME INDIA Learning Edge

  • It is crucial to prioritize educating diabetic individuals on primary healthcare and self-care practices. This study played a pivotal role in enhancing awareness and educating patients on diabetic foot care.
  • Preventing foot problems involves five essential components: identifying at-risk feet, regularly inspecting them, educating patients, families, and healthcare providers, wearing suitable footwear, and treating pre-ulcerative signs.
  • Healthcare providers should adhere to a standardized approach when evaluating foot wounds, considering type, cause, site, depth, and signs of infection to guide further therapy.
  • Ulcer treatment relies on seven key elements: relieving pressure, restoring skin perfusion, treating infections, managing metabolic factors, providing local wound care, educating patients and relatives, and preventing recurrence.
  • Successful prevention and management of foot issues in diabetes require a well-coordinated team approach, viewing ulcers as indicators of systemic disease and integrating various disciplines.

Suggested Reading

References:

  1. Singh S, Jajoo S, Shukla S, Acharya S. Educating patients of diabetes mellitus for diabetic foot care. J Family Med Prim Care. 2020 Jan 28;9(1):367-373. doi: 10.4103/jfmpc.jfmpc_861_19. PMID: 32110620; PMCID: PMC7014829.
  2. Pourkazemi, A., Ghanbari, A., Khojamli, M. et al. Diabetic foot care: knowledge and practice. BMC Endocr Disord 20, 40 (2020). https://doi.org/10.1186/s12902-020-0512-y
  3. https://www.cdc.gov/diabetes/library/features/healthy-feet.html
  4. BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5064 (Published 16 November 2017): BMJ 2017;359:j5064
  5. https://iwgdfguidelines.org/wp-content/uploads/2023/07/IWGDF-Guidelines-2023.pdf


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